A. Initial, Renewal and Change of Ownership Applications Must Include

Applicants must include the following attachments as stated in Chapters 408, Part II, and 400, Part III Florida Statues (F.S.), and Chapters 59A-35 and 59A- 8, Florida Administrative Code (F.A.C.). Applications must be received at least 60 days prior to the expiration of the current license or effective date of a change of ownership to avoid a late fine. If the renewal application is received by the Agency less than 60 days prior to the expiration date, it is subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application process or by separate notice. The application will be withdrawn from review if all the required documents and fees are not included with this application or received within 21 days of an omission notice. All forms listed below may be obtained from the website: http://ahca.myflorida.com/Publications/Forms/HQA.shtml. Send completed applications to: Agency for Health Care Administration, Home Care Unit, 2727 Mahan Drive, Mail Stop 34, Tallahassee, FL 32308.

A. Initial, Renewal and Change of Ownership Applications must include:

NOTE TO ALL APPLICANTS: The Agency will verify that all applicants, licensees and controlling interests subject to Chapters 607, 608 or 617, Florida Statutes related to Business Organizations have complied with applicable Department of State registration and filing requirements. The principal and mailing addresses submitted with any application must be the same as the addresses that appear as registered with the Department of State, Division of Corporations.

The biennial licensure fee ($1,705.00 per license) - Please make check or money order payable to the Agency for Health Care Administration (AHCA). All fees are nonrefundable. NOTE: Starter checks and temporary checks are not accepted. Additional Information Needed for RENEWAL Applications:

$300 Health Care Facility Fee Assessment ($150 annual assessment x 2). Pursuant to Rule 59C-1.022(4), Florida Administrative Code, the annual assessment from all facilities shall be collected prospectively for a two year (biennial) period. For renewal applications, the biennial assessment shall be calculated at the time of the licensure renewal and shall be due at the time of filing of the renewal application.

Health Care Licensing Application, Home Health Agency, AHCA Form 3110-1011. NOTE: All Agency correspondence will be sent to the mailing address provided in Section 1A (Provider Information) of the application. If an applicant or licensee is required to register or file with the Florida Secretary of State Division of Corporations, the principal, fictitious name and mailing address provided in Section 1B (Licensee Information) of this application must be the same as the information registered with the Division of Corporations as provided in section 59A-35.060(4), Florida Administrative Code.

Health Care Licensing Application Addendum, AHCA Form 3110-1024 - Complete the information that is applicable, write “NA” on the items that are not applicable, sign, date and send with the application (refer to Sections 3 & 4 of the application for further details).

Proof of current insurance coverage in an amount of not less than $250,000 per claim as required by section 400.471(3), F.S.

Malpractice insurance as defined in section 624.605(1)(k), F.S.; and

Liability insurance as defined in section 624.605(1)(b), F.S.

Background Screening

NOTE: All initial applicants to the Agency must first submit their application to the Agency prior to completing the background screening requirement. Once the application is received a letter will be generated and mailed to the applicant with the AHCA number and information on completing the new user registration agreement on the Background Screening results website. Once this letter is received the applicant may register on the results website to initiate the screening and select a LiveScan service provider to perform the screening. All LiveScan service providers will require the AHCA number and the agency’s ORI number to complete the screening process. Please visit the Agency’s background screening website at: http://ahca.myflorida.com/backgroundscreening

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION CHECKLIST Page 1 of 4 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml A Level 2 background screening for the Administrator and Chief Financial Officer is required every 5 years. Please check all boxes below that apply to this application:

The Administrator and/or Chief Financial Officer submitted a Level 2 screening through a LiveScan vendor approved to submit fingerprint requests through the Florida Department of Law Enforcement (FDLE). For more information regarding LiveScan vendors please see the Agency’s background screening website at: http://ahca.myflorida.com/backgroundscreening.

All screening results must be sent to the Agency for Health Care Administration (Agency) for review and eligibility determinations. If you choose to use a LiveScan source other than the Agency’s contracted vendor you must identify the Agency for Health Care Administration as the recipient of the screening results to ensure the results are reviewed by the Agency. If the Agency does not receive the result, additional screening and fees may be required.

If the service provider you choose does not have an online registration or appointment system we ask that you please use the “Validation for LiveScan Service Providers” form available on the Background Screening Results Website (https://apps.ahca.myflorida.com/SingleSignOnPortal/). The form is created after the screening is initiated on the Background Screening Results Website.

The Administrator and/or Chief Financial Officer are out of state and do not have access to a Florida LiveScan vendor and will submit a fingerprint card (you must obtain a fingerprint card from the Agency. To request a fingerprint card please contact the Agency’s Background Screening Section at (850)412-4503 or email [email protected]). The completed fingerprint card must then be submitted to:

The Agency’s contracted vendor is Cogent Systems. The fingerprint card must be filled out completely and the fingerprints taken by law enforcement personnel or individual trained in processing fingerprints. Return the completed card to:

Cogent Systems Attn: Fingerprint Card Scan Florida 5025 Bradenton Ave Suite A Dublin, OH 43017 Website: http://www.cogentid.com/fl/index_ahca.htm

Another LiveScan vendor authorized to provide services in Florida that is equipped to transmit the images of the fingerprints from the fingerprint card electronically. This requires special equipment and not all LiveScan vendors have this ability. You may find LiveScan vendor contact information on the FDLE website: http://www.fdle.state.fl.us/Content/getdoc/941d4e90-131a-45ef-8af3-3c9d4efefd8e/Livescan-Service-Providers-and- Device-Vendors.aspx.

Proof of Level 2 screening within the previous 5 years for the Administrator and/or Chief Financial Officer from the Agency, the Department of Children and Families, Department of Health, Agency for Persons with Disabilities, Department of Elder Affairs, or Department of Financial Services (if the applicant has a certificate of authority to operate a continuing care retirement community) is included with this application. An Affidavit of Compliance with Background Screening Requirements, AHCA Form 3100-0008, is also enclosed.

A. Additional Information needed for INITIAL Applications:

Evidence that the applicant has sufficient funds to operate the facility such as bank statements, net worth statements or financial reports. Please complete and submit the Proof of Financial Ability to Operate, AHCA Form 3100-0009, available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

Business Plan, signed by the applicant, describing the home health agency’s methods to obtain patients and its plan to recruit and maintain staff. Attach the business plan to the Proof of Financial Ability to Operate, AHCA Form 3100-0009.

Proof of Organization:

Partnership: Partnership Agreement; Certificate of Status; Fictitious Name filing if applicable

Corporations: Certificate of Status; Articles of Incorporation; Fictitious Name filing if applicable Limited Liability Company: Certificate of Status; Operating Agreement, Articles of Organization; Fictitious Name filing if applicable

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION CHECKLIST Page 2 of 4 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml A report or letter from the local government zoning office that the office location is zoned appropriately for use as a home health agency

Signed and notarized Distance Attestation form (only if any owners, officers or members already have a home health agency in the same county).

Proof of the licensee’s right to occupy the building such as a copy of a lease, sublease or rental agreement, or deed

Proof of federal employer identification number from the Internal Revenue Service

C. Additional Information needed for CHANGE OF OWNERSHIP Applications:

Evidence that the applicant has sufficient funds to operate the facility such as bank statements, net worth statements or financial reports. Please complete and submit the Proof of Financial Ability to Operate, AHCA Form 3100-0009, available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml

Business Plan, signed by the applicant, describing the home health agency’s methods to obtain patients and its plan to recruit and maintain staff. Attach the business plan to the Proof of Financial Ability to Operate, AHCA Form 3100-0009.

Proof of Organization:

Partnership: Partnership Agreement; Certificate of Status; Fictitious Name filing if applicable

Corporations: Certificate of Status; Articles of Incorporation; Fictitious Name filing if applicable Limited Liability Company: Certificate of Status; Operating Agreement, Articles of Organization; Fictitious Name filing if applicable

Signed and notarized Distance Attestation form (only if any owners, officers or members already have a home health agency in the same county).

A report or letter from the local government zoning office that the office location is zoned appropriately for use as a home health agency

Proof of the licensee’s right to occupy the building such as a copy of a lease, sublease or rental agreement, or deed

Proof of federal employer identification number from the Internal Revenue Service

Letter with anticipated date of transfer of ownership

Copy of signed and dated purchase agreement indicating that a change of ownership is pending

Copy of signed closing document (bill of sale) showing the date of the transfer of ownership. This document is not required initially and may be submitted after the date of the transfer. The license will not be issued until we receive this document showing that the ownership transfer has been finalized Letter from Accrediting organization granting accreditation to Buyer

FOR MEDICAID AGENCIES ONLY:

Medicaid numbers are not transferable. You must contact the Medicaid fiscal intermediary. Visit the Agency’s website at: http://ahca.myflorida.com/Medicaid/index.shtml to obtain more information.

If the home health agency is currently enrolled in any Medicaid Waiver programs, contact the department, agency or organization that enrolled the home health agency in the waiver and inform them of the change of ownership.

MEDICARE INFORMATION:

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION CHECKLIST Page 3 of 4 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml If the new owner does not intend to assume the same Medicare provider number, CMS requires advance written notification at least 45 days prior to the effective date of the change of ownership. Mail notification to:

REGIONAL ADMINISTRATOR DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE AND MEDICAID SERVICES 61 FORSYTH ST., STE. 4 T20-DMSO ATLANTA, GA 30303-8909

Please attach a copy of the notification to this application.

D. Change During Licensure Period

1. Request to change the name or address of provider:

Complete and submit sections 1, 2, 13(if Satellite) and 15 of the Health Care Licensing Application, Home Health Agency, AHCA Form 3110-1011. Submit only the sections indicated, not the entire application.

Proof of current insurance coverage in the new name or address of the provider. The coverage must be in an amount of not less than $250,000 per claim as required by section 400.471(3), F.S.

Malpractice insurance as defined in section 624.605(1)(k), F.S.; and Liability insurance as defined in section 624.605(1)(b), F.S.

For name changes provide copy of paperwork filed with the Division of Corporations

For address changes to main office or satellite or to add a satellite also include:

A report or letter from the local government zoning office that the office location is zoned appropriately for use as a home health agency; and

Proof of the licensee’s right to occupy the building such as a copy of a lease, sublease, rental agreement, or deed

$25.00 fee for replacement license or reissue of license due to change during licensure period. Please make check or money order payable to the Agency for Health Care Administration (AHCA). All fees are nonrefundable

2. Request to change the geographic service area / counties served:

Complete and submit sections 1, 2, 10 and 15 of the Health Care Licensing Application, Home Health Agency, AHCA Form 3110- 1011, if adding or deleting counties. Submit only the sections indicated, not the entire application.

If adding counties, include a written plan that describes professional staff coverage that takes into account projected number of patients and the supervision of the staff for additional counties.

$25.00 fee for replacement license or reissue of license due to change during licensure period. Please make check or money order payable to the Agency for Health Care Administration (AHCA). All fees are nonrefundable.

Notice: If you are a Medicaid provider, you may have a separate obligation to notify the Medicaid program of a name/address change, change of ownership or other change of information. Please refer to your Medicaid handbooks for additional information about Medicaid program policy regarding changes to provider enrollment information.

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION CHECKLIST Page 4 of 4 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml The Agency for Healthcare Administration scans all documents for electronic storage. In an effort to facilitate this process, we ask that you please remember to:

 Please place checks or money orders on top of the application  Include license number or case number on your check  Do not submit carbon copies of documents  Do not fold any of the documents being submitted  No Staples, Paperclips, Binder Clips, Folders, or Notebooks  Please do not bind any of the documents submitted to the Agency.

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION CHECKLIST Page 5 of 4 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml Health Care Licensing Application HOME HEALTH AGENCY

Under the authority of Chapters 408, Part II and 400, Part III, Florida Statutes (F.S.), and Chapters 59A-35 and 59A- 8, Florida Administrative Code (F.A.C.), an application is hereby made to operate a home health agency as indicated below:

1. Provider / Licensee Information

A. Provider Information – please complete the following for the home health agency name and location. Provider name, address and telephone number will be listed on http://www.floridahealthfinder.gov/ License # (for renewal & change of National Provider Identifier Medicare # (CMS CCN) Medicaid # ownership applications) (NPI) (if applicable)

Name of Home Health Agency (if operated under a fictitious name, list that here)

Street Address

City County State Zip

Telephone Number Fax Number E-mail Address Provider Website

Mailing Address or Same as above (All mail will be sent to this location)

City State Zip

Contact Person for this application Contact Telephone Number

Contact e-mail address or Do not have e-mail NOTE: By providing your e-mail address you agree to accept e-mail correspondence from the Agency

B. Licensee Information – please complete the following for the entity seeking to operate the home health agency. Licensee Name (may be same as provider name above) Federal Employer Identification Number (EIN)

Mailing Address

City State Zip

Telephone Number Fax Number E-mail Address

Description of Licensee (check one): For Profit Not for Profit Public Corporation Corporation State

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 6 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml Limited Liability Company Religious Affiliation City/County Partnership Other Hospital District Individual Other

2. Application Type and Fees

Indicate the type of application with an “X.” Applications will not be processed if all applicable fees are not included. All fees are nonrefundable. Renewal and Change of Ownership applications must be received 60 days prior to the expiration of the license or the proposed effective date of the change to avoid a late fine. If the renewal application is received by the Agency less than 60 days prior to the expiration date, it is subject to a late fee as set forth in statute. The applicant will receive notice of the amount of the late fee as part of the application process or by separate notice.

Initial Licensure

Was this entity previously licensed as a Home Health Agency in Florida? YES NO If yes, please provide the name of the agency (if different), the EIN # and the year the prior license expired or closed: NAME: EIN # Year Expired/Closed:

Renewal Licensure

Change of Ownership Proposed Effective Date:

Change during licensure period - Name/address change of the facilityProposed Effective Date:

Change during licensure period - Add/delete counties Proposed Effective Date:

Action Fee TOTAL FEES

LICENSE FEE (Initial, Renewal and Change of Ownership): License Fee Exemption (State, County $1,705.00 $ or Municipal Government pursuant to 400.471(5), F.S.) = $ 0.00 Biennial Assessment (Renewal application $300.00 only) $ Change During Licensure $ 25.00 $ Period/Replacement License TOTAL FEES INCLUDED WITH APPLICATION: $ Please make check or money order payable to the Agency for Health Care Administration (AHCA) NOTE: Starter checks and temporary checks are not accepted.

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 7 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml 3. Controlling Interests of Licensee

AUTHORITY:

Pursuant to section 408.806(1)(a) and (b), Florida Statutes, an application for licensure must include: the name, address and Social Security number of the applicant and each controlling interest, if the applicant or controlling interest is an individual; and the name, address, and federal employer identification number (EIN) of the applicant and each controlling interest, if the applicant or controlling interest is not an individual. Disclosure of Social Security number(s) is mandatory. The Agency for Health Care Administration shall use such information for purposes of securing the proper identification of persons listed on this application for licensure. However, in an effort to protect all personal information, do not include Social Security numbers on this form. All Social Security numbers must be entered on the Health Care Licensing Application Addendum, AHCA Form 3110-1024.

DEFINITIONS:

Controlling interests, as defined in subsection 408.803(7), Florida Statutes, are the applicant or licensee; a person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the applicant or licensee; or a person or entity that serves as an officer of, is on the board of directors of, or has a 5-percent or greater ownership interest in the management company or other entity, related or unrelated, with which the applicant or licensee contracts to manage the provider. The term does not include a voluntary board member.

Voluntary Board Member, as defined in subsection 408.803(13), Florida Statutes, means a board member or officer of a not-for-profit corporation or organization who serves solely in a voluntary capacity, does not receive any remuneration for his or her services on the board of directors, and has no financial interest in the corporation or organization.

In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the licensee. Attach additional sheets if necessary.

A. Individual and/or Entity Ownership of Licensee

FULL NAME of INDIVIDUAL or TELEPHONE EIN % OWNERSHIP PERSONAL OR BUSINESS ADDRESS ENTITY NUMBER (No SSNs) INTEREST

B. Board Members and Officers of Licensee

TELEPHONE % OWNERSHIP TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS NUMBER INTEREST Director/CEO President Vice President AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 8 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml Secretary Treasurer Other:

C. Voluntary Board Members and Officers of Licensee If the licensee is a not-for-profit corporation/organization, provide the requested information for each individual that serves as a voluntary board member. Attach additional sheets if necessary.

FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER

D. Administration

Full Name Home Address (include zip code) Telephone Number Administrator Per subsection 400.476(1), Florida Statues, the administrator can only work for home health agencies that share identical controlling interests. (Refer to subsection 408.803(7), Florida Statutes regarding controlling interests).Administrator cannot be DON if there are 10 full time equivalent staff including contracted personnel working in the home health agency. Required Experience:

Physician License #:

Registered Nurse License #:

One year of supervisory or administrative experience in home health care or in a facility licensed under chapter 395 (hospital), chapter 400, Part II (nursing home), or under chapter 429, Part I (assisted living facility). Full time or Part time

Alternate Full Name Home Address(include zip code) Telephone Number Administrator Per subsection 400.476(1), Florida Statues, the alternate administrator can only work for home health agencies that share identical controlling interests. (Refer to subsection 408.803(7), Florida Statutes regarding controlling interests). Required Experience:

Physician License #:

Registered Nurse License #:

One year of supervisory or administrative experience in home health care or in a facility licensed under chapter 395 (hospital), chapter 400, Part II (nursing home), or under chapter 429, Part I (assisted living facility). Full time or Part time

Full Name Home Address (include zip code) Telephone Number Director of Nursing Per subsection 400.476(2), F.S., the DON can only work for home health agencies that share identical controlling interests. AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 9 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml (Refer to subsection 408.803(7), Florida Statutes regarding controlling interests.)If providing only non-skilled services a DON is not required but the home health agency must have an RN to supervise the provision of services by home health aides, CNA’s, and LPN’s. Required Experience: One year of supervisory experience as a registered nurse. License Number:

Full time or Part time

Full Name Home Address (include zip code) Telephone Number Alternate DON

Required Experience: One year of supervisory experience as a registered nurse. License Number:

Full time or Part time

Full Name Home Address (include zip coe0 Telephone Number RN (non-skilled service agencies who are not Medicare or Medicaid certified)

Full time Part time or Contract License Number:

Chief Financial Full Name Home Address (include zip code) Telephone Number Officer Full time Part time or Contract

E. Nonimmigrant Aliens If the applicant or any controlling interests are nonimmigrant aliens, then a surety bond of at least $500,000 must be filed, payable to AHCA, that guarantees the home health agency will act in full conformity with all legal requirements for operation (408.8065(2), F.S.). Please send evidence of the surety bond with the application. [Nonimmigrant is defined by the Department of Homeland Security as: An alien who seeks temporary entry to the United States for a specific purpose. The alien must have a permanent residence abroad (for most classes of admission) and qualify for the nonimmigrant classification sought. The nonimmigrant classifications include: foreign government officials, visitors for business and for pleasure, aliens in transit through the United States, treaty traders and investors, students, international representatives, temporary workers and trainees, representatives of foreign information media, exchange visitors, fiancé(e)s of U.S. citizens, intracompany transferees, NATO officials, religious workers, and some others. Most nonimmigrant’s can be accompanied or joined by spouses and unmarried minor (or dependent) children.] Are there any nonimmigrant aliens listed as a licensee or controlling interest in this application?

YES (enclose evidence of a surety bond with this application) NO

4. Management Company Controlling Interests

Does a company other than the licensee manage the licensed provider? If NO, skip to section 5 – Required Disclosure. If YES, provide the following information:

Name of Management Company EIN (No SSN) Telephone Number / Fax

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 10 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml Street Address E-mail Address

City County State Zip

Mailing Address or Same as above

City State Zip

Contact Person Contact E-mail Contact Telephone Number

In Sections A and B below, provide the information for each individual or entity (corporation, partnership, association) with 5% or greater ownership interest in the management company. Attach additional sheets if necessary.

A. Individual and/or Entity Ownership of Management Company

% EIN FULL NAME of INDIVIDUAL or PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER OWNERSHIP (No SSNs) ENTITY INTEREST

B. Board Members and Officers of Management Company

% TITLE FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE OWNERSHIP NUMBER INTEREST Director/CEO President Vice President Secretary Treasurer Other:

C. Voluntary Board Members and Officers of Management Company

If the management company is a not-for-profit corporation/organization, provide the requested information for each individual that serves as a voluntary board member. Attach additional sheets if necessary

FULL NAME PERSONAL OR BUSINESS ADDRESS TELEPHONE NUMBER

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 11 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml D. Nonimmigrant Aliens If the applicant or any controlling interests of the management company are nonimmigrant aliens, then a surety bond of at least $500,000 must be filed, payable to AHCA, that guarantees the home health agency will act in full conformity with all legal requirements for operation (408.8065(2), F.S.). Please send evidence of the surety bond with the application.

[Nonimmigrant is defined by the Department of Homeland Security as: An alien who seeks temporary entry to the United States for a specific purpose. The alien must have a permanent residence abroad (for most classes of admission) and qualify for the nonimmigrant classification sought. The nonimmigrant classifications include: foreign government officials, visitors for business and for pleasure, aliens in transit through the United States, treaty traders and investors, students, international representatives, temporary workers and trainees, representatives of foreign information media, exchange visitors, fiancé(e)s of U.S. citizens, intracompany transferees, NATO officials, religious workers, and some others. Most nonimmigrant’s can be accompanied or joined by spouses and unmarried minor (or dependent) children.]

Are there any nonimmigrant aliens listed as a owner or controlling interest of the management company?

YES (enclose evidence of a surety bond with this application) NO

5. Required Disclosure

The following disclosures are required:

A. Pursuant to subsection 408.809(1)(d), F.S., the applicant shall submit to the agency a description and explanation of any convictions of offenses prohibited by sections 435.04 and 408.809(5), F.S., for each controlling interest. Has the applicant or any individual listed in sections 3 and 4 of this application been convicted of any level 2 offense pursuant to subsection 408.809(1)(d), Florida Statutes? (These offenses are listed on the Affidavit of Compliance with Background Screening Requirements, AHCA Form #3100-0008.) YES NO

If yes, enclose the following information: The full legal name of the individual and the position held

A description/explanation of the conviction(s) - If the individual has received an exemption from disqualification for the offense, include a copy

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 12 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml B. Pursuant to section 408.810(2), F.S., the applicant must provide a description and explanation of any exclusions, suspensions, or terminations from the Medicare, Medicaid, or federal Clinical Laboratory Improvement Amendment (CLIA) programs.

Has the applicant or any individual listed in Sections 3 and 4 of this application been excluded, suspended, terminated or involuntarily withdrawn from participation in Medicare or Medicaid in any state? YES NO

If yes, enclose the following information: The full legal name of the individual and the position held

A description/explanation of the exclusion, suspension, termination or involuntary withdrawal.

C. Pursuant to section 408.815(4), F.S., does the applicant or any controlling interest in an applicant have any of the following:

YES NO Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, chapter 893, 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, within the previous 15 years prior to the date of this application;

YES NO Terminated for cause from the Florida Medicaid program pursuant to s. 409.913, and not been in good standing with the Florida Medicaid program for the most recent 5 years;

YES NO Terminated for cause, pursuant to the appeals procedures established by the state or Federal Government, from the federal Medicare program or from any other state Medicaid program, have not been in good standing with a state Medicaid program or the federal Medicare program for the most recent 5 years and the termination was less than 20 years prior to the date of this application.

6. Provider Fines and Financial Information

Pursuant to subsection 408.831(1)(a), Florida Statutes, the Agency may take action against the applicant, licensee, or a licensee which shares a common controlling interest with the applicant if they have failed to pay all outstanding fines, liens, or overpayments assessed by final order of the agency or final order of the Centers for Medicare and Medicaid Services (CMS), not subject to further appeal, unless a repayment plan is approved by the agency.

Are there any incidences of outstanding fines, liens or overpayments as described above? YES NO

If yes, please complete the following for each incidence (attach additional sheets if necessary):

Amount: $ assessed by: Agency for Health Care Administration CMS Date of related inspection, application or overpayment period if applicable: Due date of payment: Is there an appeal pending from a Final Order? YES NO

Please attach a copy of the approved repayment plan if applicable.

7. Federal Certification and Other Federal Provider Numbers

Does the licensed provider participate in the: Does the initial applicant intend to participate in the: Medicaid program? YES NO Medicaid program? YES NO

Medicare program? YES NO Medicare program? YES NO

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 13 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml Is this is a branch or subunit of an existing Medicare/Medicaid provider? YES NO If yes, provide the following:

MEDICARE MEDICAID NAME OF PARENT AGENCY ADDRESS NUMBER NUMBER

If you plan to participate in Medicaid: Visit the Agency’s website at: http://ahca.myflorida.com/Medicaid/index.shtml in order to obtain information and an application for enrollment in Medicaid.

If you plan to participate in Medicare: The Medicare Provider Application (CMS Form 855) is available from the fiscal intermediary or on the Center for Medicare and Medicaid Services (CMS) website at: www.cms.hhs.gov/cmsforms/. The form must be sent directly to the chosen fiscal intermediary for review.

OTHER MEDICAID PROVIDER NUMBERS: Do you participate in any Medicaid Waivers or other programs that you provide services for patients that you bill to Medicaid? Please list each Provider Type and Number below: attach additional sheets if necessary.

Type of Medicaid Waiver or Specialty Code Provider Number 1 2 3 4 5

8. Other Provider Relations

Does the licensee, owner or other controlling interest own or serve as a director or officer for any other licensed health care provider including any registrations for Homemaker/Companion in Florida? YES NO If yes, provide the following information; attach additional sheets, if necessary:

PROVIDER NAME PROVIDER TYPE LICENSE NUMBER CITY EIN (No SSNs)

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 14 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml 9. Personnel A. Please provide the following information on Service Personnel. NOTE: “Direct employees” are those for whom the agency pays withholding taxes. State rules require that a licensed-only agency provide at least one of the services listed below by direct employees. If providing nursing services, some of the service must be provided by a direct employee as required in state law, section 400.487(5), F.S. Federal regulations require that Medicare and Medicaid agencies provide one of the skilled services (*) below totally by direct employees. (Medicaid does not include Medical Social Services as a home health agency service).

# DIRECT # CONTRACTED IF SUB-CONTRACT FROM ANOTHER AGENCY, PERSONNEL EMPLOYEES EMPLOYEES WRITE AGENCY NAME BELOW Nursing* Physical Therapy* Speech Therapy* Occupational Therapy* Respiratory Therapy IV Therapy Home Health Aide* Homemaker / Companion Nutritional Guidance Medical Equipment & Supplies Medical Social Services* Other: B. RENEWAL APPLICATIONS ONLY: Pursuant to section 400.471.(2)(c), F.S., provide the number of patients admitted by your Home Health Agency’s most recent fiscal year, last calendar year or most recent 12 month period: . C. Does your home health agency provide skilled services to children under the age 21? Yes No 10. Geographic Service Area

For initial applications list all counties where this agency expects to provide services. For all other applications, list only those counties that this agency plans to add (A) or delete (D) counties from the existing license.

NOTE: Counties must be within a single AHCA area (see below) COUNTY (A)dd / (D)elete COUNTY (A)dd / (D)elete 1. 9. 2. 10. 3. 11. 4. 12. 5. 13. 6. 14. 7. 15. 8. 16. AHCA Area 1: Escambia, Okaloosa, Santa Rosa, Walton; AHCA Area 2: Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington; AHCA Area 3: Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union. AHCA Area 4: Duval, Baker, Clay, Flagler, Nassau, St. Johns, Volusia; AHCA Area 5: Pasco, Pinellas; AHCA Area 6: Hardee, Highlands, Hillsborough, Manatee, Polk; AHCA Area 7: Brevard, Orange, Osceola, Seminole; AHCA Area 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, Sarasota; AHCA Area 9: Indian River, Martin, Okeechobee, Palm Beach, St. Lucie; AHCA Area 10: Broward; AHCA Area 11: Dade, Monroe.

ADD COUNTY(IES): Include a written plan that describes professional staff coverage that takes into account projected number of patients and the supervision of the staff for the additional counties.

DELETE COUNTY(IES): Indicate which counties to be deleted from license.

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 15 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml 11. Days and Hours of Operation

List the regular operating hours. Section 59A-8.003(10)(a), F.A.C., requires that an agency be open for 8 consecutive hours per day, Monday through Friday between the hours of 7 a.m. and 6 p.m., excluding legal and religious holidays:

Day of the Week Opening Time Closing Time Monday Tuesday Wednesday Thursday Friday Indicate if the agency will have a 24-hour on-call system (required for agencies offering skilled services). NOTE: Site inspections by surveyors will occur during the business hours submitted. Failure to be open during the listed hours may result in a fine.

12. Accreditation / Deemed Status

Initial Applicants: Effective July 1, 2008 new applicants for home health licensure must submit either: (select one) proof of accreditation or proof of application for accreditation from an accrediting organization listed below. Within 120 days of the Agency’s receipt of the licensure application, the applicant must obtain accreditation that is not conditional or provisional. The accreditation must be maintained at all times to keep licensure as a home health agency per subsection 400.471(2)(h), F.S.

Renewal Applicants: If you applied and were licensed after July 1, 2008, you must be accredited with one of the accrediting organizations listed below. Please check the appropriate accrediting organization and include a current copy of your accreditation report with this application.

Renewal Applications with prior accreditation and/or deemed status: If your agency is still accredited or accredited and deemed, please check the appropriate accrediting organization box below and include a current copy of your accreditation and/or deemed status report.

Accrediting Organization

Joint Commission (JC) Community Health Accreditation Accreditation Commission for Program (CHAP) Health Care (ACHC)

Expiration date of accreditation:

Proof of accreditation enclosed

Proof of application for accreditation – a screen print receipt from accrediting organization web site or letter of receipt of application from accrediting organization.

No longer accredited and/or deemed

Not applicable/licensed prior to July 1, 2008

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 16 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml 13. Satellite Office

A satellite office is a secondary office in the same county as the main office, operating under the auspices of the main office’s license. Refer to section 59A-8.003(7), F.A.C., for requirements.

WILL THIS AGENCY OPERATE A SATELLITE OFFICE? YES NO

If yes, list address(es) of Satellite offices below:

Street Address

City Zip County Telephone Number

Street Address

NOTE: For each satellite office enclose a report or letter from the local government zoning office that the building is zoned appropriately for use as a home health agency and evidence of legal right to occupy the office such as a lease, deed, rental agreement or contract.

14. Drop-Off Site

A drop-off site may be located in any county within the licensed geographic service area. This is merely a workstation for direct care staff. Neither billing nor prospective patient contact is allowed. Refer to section 59A-8.003(8), F.A.C., for requirements.

WILL THIS AGENCY OPERATE A DROP-OFF SITE? YES NO

If yes, list address(es) of Drop-Off Sites below:

Street Address

City Zip County

Street Address

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 17 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml City Zip County

Street Address

City Zip County

15. Affidavit

I, , hereby swear or affirm, under penalty of perjury, that the statements in this application are true and correct.

As administrator or authorized representative of the above named provider/facility, I hereby attest that all employees required by law to undergo Level 2 background screening have met the minimum standards of sections 435.04, and 408.809(5), Florida Statutes (F.S.) or are awaiting screening results. I also attest that all personnel hired or contracted with or registered on or after October 1, 2000, who enter the home of a patient or client in their service capacity have been screened using the Level 1 standards as provided in section 435(03) and section 400.512, F.S.

In addition, I attest that all employees subject to Level 2 screening standards have attested to meeting the requirements for qualifying for employment and agree to inform me immediately if arrested for or convicted of any of the disqualifying offenses while employed here as specified in subsection 435.04(5), F.S.

Signature of Licensee or Authorized Representative Title Date

AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 18 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml AHCA Recommended Form 3110-1011, Revised September 2013 Section 59A-35.060(1), Florida Administrative Code APPLICATION Page 19 of 12 Forms available at: http://ahca.myflorida.com/Publications/Forms/HQA.shtml